Asymptomatic COVID-19-Associated Acquired Hemophilia A and Disseminated Intravascular Coagulation From a Bypassing Agent.

Acquired hemophilia A (AHA) is a clotting disorder characterized by the presence of neutralizing antibodies that inhibit factor VIII, resulting in increased bleeding risk. Known etiologies include malignancy, autoimmune conditions, graft-vs-host disease, and more recently coronavirus disease 2019 (COVID-19) infection. In this case report, we describe an 86-year-old female who was found to have AHA incidentally during preoperative workup for meningioma resection. She was subsequently found to have COVID-19 infection which was the likely cause of her development of AHA. She was treated with factor eight inhibitor bypassing agent (FEIBA) and recombinant factor VII (rVII) for a small hematoma on her right arm along with prednisone and cyclophosphamide. She then developed disseminated intravascular coagulation (DIC) initially secondary to FEIBA and subsequently rFVII. DIC resolved after these factor concentrates were withheld. The aim of this case report was to emphasize the importance of monitoring partial thromboplastin time (PTT) in patients with COVID-19 and proceeding with AHA workup if indicated. It is also imperative to know and understand the potentially life-threatening, albeit rare, adverse effects of DIC associated with the administration of factor concentrates, especially in the elderly population and withholding these factor concentrates once DIC is suspected.

The Influence of the Microbiome on Immunotherapy for Gastroesophageal Cancer.

Immunotherapy has shown promise as a treatment option for gastroesophageal cancer, but its effectiveness is limited in many patients due to the immunosuppressive tumor microenvironment (TME) commonly found in gastrointestinal tumors. This paper explores the impact of the microbiome on the TME and immunotherapy outcomes in gastroesophageal cancer. The microbiome, comprising microorganisms within the gastrointestinal tract, as well as within malignant tissue, plays a crucial role in modulating immune responses and tumor development. Dysbiosis and reduced microbial diversity are associated with poor response rates and treatment resistance, while specific microbial profiles correlate with improved outcomes. Understanding the complex interactions between the microbiome, tumor biology, and immunotherapy is crucial for developing targeted interventions. Microbiome-based biomarkers may enable personalized treatment approaches and prediction of patient response. Interventions targeting the microbiome, such as microbiota-based therapeutics and dietary modifications, offer the potential for reshaping the gut microbiota and creating a favorable TME that enhances immunotherapy efficacy. Further research is needed to reveal the underlying mechanisms, and large-scale clinical trials will be required to validate the efficacy of microbiome-targeted interventions.

Overwhelming Sepsis due to Capnocytophaga canimorsus in an Immunocompetent Individual: A Rare Case Study.

We report this rare case of fatal fulminant sepsis in a 42-year-old African American female who presented with a three-day history of generalized pain and an evolving rash all over her body. On presentation, the patient was tachycardic, borderline hypotensive, and febrile. Physical examination was significant for diffuse petechiae and ecchymoses over the extremities, torso, and the face, especially confluent over her thighs and lower abdomen. She was admitted to the ICU, and initial investigations revealed a normal leukocyte count and hemoglobin but severe thrombocytopenia, elevated creatinine, blood urea nitrogen (BUN), bilirubin, transaminases, and an elevated INR. She also had a high anion gap metabolic acidosis with elevated lactate. Chest and abdomen CT findings were nonspecific, demonstrating fluid surrounding both kidneys, a moderate amount of fluid in the pelvis, and alveolar opacities at the bases of both lungs. Initial working diagnoses were a septic shock, thrombotic thrombocytopenic purpura (TTP), and vasculitis. She was initiated on broad-spectrum antibiotic coverage with vancomycin, piperacillin/tazobactam, and doxycycline pending culture reports. After a few hours, she became progressively hypothermic, developed disseminated intravascular coagulation (DIC) and hemodynamic instability, and was intubated due to acute hypoxic and hypercapnic respiratory failure. She progressively worsened hemodynamically with multi-organ dysfunction, and ultimately was pronounced dead roughly 18 hours after initial presentation. Blood cultures grew a Gram-negative organism, initially reported as Shewanella putrefaciens, but subsequently confirmed as Capnocytophaga canimorsus.

Primary Vaginal Malignant Melanoma: A Case Report and Review of Literature.

Primary vaginal malignant melanoma is an extremely rare and aggressive tumor with very few reported cases worldwide. It often occurs in post-menopausal women, with a mean age of 57 years. The most common presenting symptom is vaginal bleeding. Other less common presenting symptoms are vaginal discharge, vaginal mass, and pain. Vaginal melanomas are often diagnosed at an advanced stage, and despite the aggressive treatment approach, the prognosis is poor. We present to you a case of a 56-year-old post-menopausal woman who presented with intermittent vaginal bleeding and passage of dark clots. She was found to have symptomatic anemia requiring blood transfusions. Further workup revealed a mass in the upper vagina on imaging studies, and the patient eventually underwent a biopsy, which confirmed the diagnosis of malignant melanoma of the vagina on pathological examination.

A Rare Case of Small Cell Carcinoma of the Urinary Bladder.

Small cell carcinoma of the bladder is a rare type of bladder malignancy. Based on most of the existing studies, there is an observed male predominance, usually in their sixties or seventies, and they are more likely to have a history of smoking. Additionally, there is a higher predilection for Caucasians (versus non-Caucasians). The most common presenting complaint is painless macroscopic hematuria. However, other presenting symptoms also include dysuria, difficulty voiding, weight loss, abdominal pain, nocturia, and urinary frequency. It is not uncommon to have a history of frequent urinary tract infections, ureteral obstruction, and paraneoplastic syndromes. Cystoscopy is the "gold standard" for evaluation of urinary tract lining, especially in conjunction with narrow-band imaging and biopsy. Transurethral resection of the bladder tumor (TURBT) is the next step in diagnosis and treatment that allows to precisely evaluate pathology and the extent of bladder wall involvement, and is a sufficient surgical approach for the treatment of non-muscle invasive tumors. Once tumor pathology is confirmed, a treatment plan is determined based on the staging. Although both lung and bladder small cell carcinoma have similarities in pathogenesis, genomic alterations in small cell carcinoma of the bladder are more similar to that of urothelial cancer rather than small cell lung cancer. As this is a rare subtype and only a few reported cases are available, no standard treatment regimen has been established. In localized disease, neo-adjuvant platinum-based chemotherapy with cystectomy has been shown to provide the best result in retrospective studies. As this type of cancer has a poor prognosis, in metastatic disease, palliative chemotherapy is offered. Here we present one such case of small cell carcinoma of the bladder and review the current literature.